Category: Obstructive Sleep Apnea

 Quality, in addition to quantity, is important for maintaining health, according to a research abstract that will be presented on Wednesday, June 10, at SLEEP 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies.

Results indicate that over the average follow-up of eight years, 854 of the 5,614 participants died. Two sleep-stage transition types were associated with higher mortality risk: wake-to-non-REM and non-REM-to-wake.

According to lead author Alison Laffan, PhD, former graduate student at the Johns Hopkins Bloomberg School of Public Health and current post-doctoral fellow at the California Pacific Medical Center in San Francisco, Calif., mounting evidence from a number of studies shows that poor sleep increases risk for adverse health outcomes.

"In light of this growing body of evidence, people should strive to maintain good sleep habits, such as going to bed and getting up at the same time each day and sleeping for seven to eight hours each night," said Laffan.

The study involved data from 5,614 Sleep Heart Health Study participants who underwent overnight polysomnography to characterize sleep. Health outcomes were monitored for the following eight years. Sleep fragmentation was defined using an index of the number of sleep stage transitions per hour of sleep. In addition to a composite transition index, indexes of each of the six types of transitions were also tested. The relative risk of death as a function of each transition index was calculated using proportional hazards models, adjusting for age, gender, body mass index, race, hypertension, cardiovascular disease, smoking status, respiratory disturbance index and arousal index.

According to the authors of the study, obstructive sleep apnea (OSA), a major cause of sleep fragmentation, has been linked to increased risk for all-cause mortality; however, most studies have not directly measured fragmentation. Findings of this study were able to directly measure the relationship between sleep fragmentation and mortality.

People with chronic stress report shorter sleep duration, worse sleep quality, and more daytime functioning impairments, according to a research abstract that will be presented on Wednesday, June 10, at SLEEP 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies. Conversely, daytime functioning impairments and shorter sleep duration demonstrated a predictive relationship with habitual stress complaints.

Results indicate that poor sleep may be a potential cause of stress; individuals who report more fatigue and less total sleep are more likely to report more stress.

According to principal investigator Eric Powell, PhD, director of research at the Research Center at Clayton Sleep Institute in St. Louis, Mo., factors that were the best predictors of high stress were daytime functioning and typical amount of sleep.

"The simplest, and likely best advice for individuals with high stress and poor sleep is to look at some of the lifestyle choices they are making and ensuring sufficient sleep is at the core of those choices," said Powell.

The study involved data from 544 patients at the Midwestern metropolitan sleep center who received diagnostic polysomnograms. Participants ranged in age from 18 to 79 years, were not shift workers, and had no prior sleep disorder diagnosis. Subjects completed a brief estimate of their state and trait stress, and sleepiness was assessed subjectively; individuals were divided into low and high-trait stress groups.

According to a research abstract that will be presented on June 9, at Sleep 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies, adolescent obesity is associated with having less sleep. Reduction in sleep could be related to a higher caffeine intake, more hours of technology use and increased symptoms of sleep disorders (such as snoring).

Results indicate that children who slept less consumed more caffeine and had more hours of screen time (use of television, Internet, computer and video games). A higher body mass index (BMI) was also associated with shorter sleep duration. More hours of screen time were also associated with higher caffeine consumption.

According to lead author Amy Drescher, PhD, research specialist at the University of Arizona in Tucson, there are many reasons that kids gain weight, and inadequate sleep is just one of them.

"Boys had significantly more vigorous exercise, recreational activity than girls," said Drescher. "The sleep and obesity connection is not always seen because factors such as exercise may keep weight in check."

The study gathered data from 320 children who completed detailed dietary and physical activity questionnaires. Correlation and regression analysis were used to study the relationships among diet, physical activity and self-reported sleep duration and screen time. Mean age of the sample group was 13.3 years; 51.8 percent of participants were male, 65 percent were Caucasian and 35 percent were Hispanic.

Inadequate sleep combined with increased electronic screen time and caffeine intake may have negative implications for adolescents' health, psychosocial well-being and academic performance.

Abstract Title: Associations Between Sleep, and Dietary, Exercise and Electronic Screen Habits of Adolescents in the Tucson Children's Assessment of Sleep Apnea (TuCASA) study

Nearly 1 in 10 patients with obstructive sleep apnea also experience "parasomnia" symptoms such as sleepwalking, hallucinations and acting out their dreams, a Loyola University Chicago Stritch School of Medicine study has found.

Researchers examined records of 537 adult sleep apnea patients who were evaluated at the Loyola Center for Sleep Disorders in Maywood and Oak Brook Terrace. Fifty-one patients, or 9.5 percent of the total, reported one or more types of parasomnia symptoms.

Parasomnia complaints included sleep paralysis (21 patients), sleep-related hallucinations (16 patients), acting out dreams (11 patients), sleepwalking (5 patients) and eating while asleep (one patient).

Results were reported at Sleep 2009, the annual meeting of the Associated Professional Sleep Societies, held this year in Seattle.

Obstructive sleep apnea is caused by a partial or complete blockage of the airway. Each time this happens, the brain becomes aroused, in order to resume breathing. This is disruptive to sleep, and the patient can feel chronically tired during the day.

Earlier studies found that obstructive sleep apnea is associated with a higher risk of high blood pressure, heart attacks, stroke, obesity, diabetes, heart failure and irregular heartbeats. The new study suggests that apnea also is linked to increased parasomnia symptoms.

Parasomnia disorders include sleep paralysis (brief episodes of being unable to move), hallucinations during the state between waking and sleeping, acting-out dreams (punching, kicking, crying out, etc.) and walking, eating or even driving while asleep.

Because it interrupts sleep, apnea can set a person up for parasomnia, said Dr. Nidhi S. Undevia, principal investigator of the study. "If you have a predisposition to parasomnia, apnea could make it worse," Undevia said. Undevia is medical director of the Loyola Center for Sleep Disorders and an assistant professor in the Department of Critical Care Medicine at Loyola University Chicago Stritch School of Medicine.

Undevia said doctors should ask apnea patients if they have parasomnia symptoms. "We need to start asking, because we might be missing potentially dangerous or harmful behaviors," she said.

Other co-authors are Loyola sleep specialist Dr. Sunita Kumar, an assistant professor in the Department of Critical Care Medicine at Stritch School of Medicine and lead author Dr. Mari Viola-Saltzman, a sleep medicine fellow at the University of Washington. During the course of the study, Viola-Saltzman was a neurology resident at Loyola University Hospital.

Viola-Saltzman said that, in addition to screening patients for snoring, apneic spells, disrupted sleep and daytime somnolence, physicians "may also consider asking about parasomnia symptoms as another tool to indicate whether the patient may be suffering from obstructive sleep apnea."

Primary care pediatricians may be under-diagnosing sleep disorders in children and teens, according to a research abstract that will be presented on June 8 at Sleep 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies.

The study obtained data from 32 primary care pediatric practices affiliated with Children's Hospital of Philadelphia. Information was gathered by chart review for 154,957 patients, ranging in age from 0 to 18 years. Results show that less than four percent (5750 children) were diagnosed with a sleep disorder. The most common diagnoses were sleep disorders that are "not otherwise specified" (1.42 percent), enuresis – or bedwetting (1.24 percent), sleep disordered breathing (1.04 percent), and insomnia (0.05 percent).

According to lead author Lisa Meltzer, PhD, the rate of diagnosis found in this study is significantly lower than prevalence rates reported in epidemiological studies.

"Sleep is often discussed during check-ups for young children, but it may not come up as a topic with teenagers, resulting in an under diagnosis of sleep disorders for this group of adolescents," said Meltzer. "Pediatricians should ask about sleep during every well-child visit. Children who snore, have problems falling asleep, are difficult to wake in the morning, or who fall asleep in school should be further evaluated for sleep disorders."

Because sleep problems in children can have a major impact on learning, growth and development, the authors advise that it is important for pediatricians to receive education and support in the diagnosis and treatment of sleep disorders.

According to the American Academy of Sleep Medicine (AASM), some signs that your child may have a sleep problem include:

• You spend too much time "helping" your child fall asleep
• Your child wakes up repeatedly during the night.
• Your child snores very loudly or struggles to breathe during sleep.
• Your child's behavior, mood or school performance changes.
• Your child who used to stay dry at night begins to wet the bed.

Abstract Title: Prevalence of Sleep Disorders in Pediatric Primary Care Practice

Men with insomnia and sleep duration of six or fewer hours of nightly sleep are at an increased risk for mortality, according to a research abstract that will be presented on June 8, at Sleep 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies.

Results indicate that compared to people who sleep six hours or more, men with insomnia and less than six hours of nightly sleep were at highest risk of mortality. The mortality rate of the sample was 19.6 percent for men versus 10.3 percent for women.

The study included data from 1,741 men and women who were randomly selected from Central Pennsylvania. Participants were studied in a sleep laboratory; follow-ups were conducted over the course of 14 years for men and 10 years for women. Insomnia was defined by a complaint of insomnia with duration of greater than a year, while "poor sleep" was defined as a complaint of difficulty falling asleep, staying asleep or early final awakening. Polysomnographic sleep duration was classified into two categories; people who slept greater than six hours, and those who slept for less than six hours.

According to the lead author, Alexandros Vgontzas, MD, endowed chair in Sleep Disorders Medicine at Penn State College of Medicine in Hershey, PA., insomnia is associated with medical morbidity and mortality rates similar to those seen in patients with obstructive sleep apnea.

"Based on clinical experience and pervious studies, we can speculate that medication and cognitive behavioral therapy (CBT) or a combination of the two can be used to extend sleep duration and reduce the risk of mortality," said Vgontzas.

Other studies have also found serious medical risks associated with insomnia and objective short sleep duration; another study led by Vgontzas that will presented at SLEEP 2009 found that insomnia with objective short sleep duration is also associated with increased risk of diabetes.

Authors of the study claim that findings indicate that people with insomnia should seek evaluation and treatment from their medical provider. Although the results suggest that people with insomnia have a lower risk for physical problems if their sleep duration is normal, they still are at increased risk for depression and may suffer from the behavioral effects of insomnia.

Abstract Title: Insomnia with objective short sleep duration is associated with increased mortality in men

According to a research abstract that will be presented on June 8, at Sleep 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies, race significantly influences the risk of obesity conferred by short sleep duration, with blacks having a greater risk than whites.

Results indicate that short sleep was associated with obesity, with the adjusted odds ratios for black Americans (1.78) and white Americans (1.43) showing that blacks had a 35 percent greater risk than whites of obesity associated with short sleep. The prevalence of obesity (body mass index of 30 or higher) was 52 percent for blacks and 38 percent for whites. The prevalence of short sleep (5 hours or less) was 12 percent for blacks and eight percent for whites.

According to lead author Girardin Jean-Louis, PhD, associate professor at the SUNY Downstate Medical Center at the Brooklyn Health Disparities Research Center in New York, the findings suggest that short sleep time may be a contributor to the obesity crisis. Previous studies have established that individuals who sleep for less than seven hours per night may be at a greater risk for becoming obese.

"Compared to white Americans, black Americans had a greater prevalence of short sleep (five hours of sleep per night or less) and a greater prevalence of obesity. Both black and white Americans who were obese tended to have short sleep duration," said Jean-Louis.

The study analyzed data from 29,818 individuals who completed the 2005 National Health Interview Survey, a cross-sectional household interview survey using multistage area probability and design. Data were collected from all 50 states and Washington, D.C. Participants were between the ages of 18 and 85 years; 85 percent of the sample was white and 15 percent was black; 56 percent of participants were women.

According to the authors, black Americans may have an increased risk for obstructive sleep apnea and diabetes, both of which are associated with obesity.

Abstract Title: Short sleep duration and the risk of obesity among black and white Americans

Men who work with their female partners while receiving continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) are more likely to adhere to their treatment, according to a research abstract that will be presented at Sleep 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies.

Results indicate that patients who work with their partners have the highest level of adherence for CPAP therapy. Encouragement, the use of negative tactics (such as evoking fear or blame) and reminding did not produce an increase in treatment adherence.

The study obtained demographic and relationship quality information from 23 married/cohabitating male OSA patients before CPAP initiation, and included adherence data from 14 men. Partner involvement with CPAP was assessed at day 10 and three months post CPAP initiation using 25-item measure of tactics to encourage healthful behavior. Tactics used included positive (encouraging) negative (blaming) bilateral (working together) and unilateral (reminding).

According to the principal investigator, Kelly Glazer Baron, PhD, postdoctoral fellow at Northwestern University in Evanston, Ill., the study showed that patients who believed that their relationships were more supportive were more likely to work together with their partner while using CPAP.

"We know that in many health conditions, having a supportive partner can improve adherence and emotional well being when dealing with a chronic illness," said Baron. "This is the first study in CPAP treatment to show that working together with the partner in an active and supportive manner was associated with better adherence."

CPAP is the most common and effective treatment for OSA. By working to normalize breathing, CPAP helps protect patients from the severe health risks that are related to OSA, which include heart disease, diabetes, hypertension, and stroke.

Abstract Title: Partner Involvement in CPAP: Does Pressure help?

It has been linked to learning impairment, stroke and premature death. Now UNSW research has found that snoring associated with sleep apnea may impair brain function more than previously thought.

Sufferers of obstructive sleep apnea experience similar changes in brain biochemistry as people who have had a severe stroke or who are dying, the research shows.

A study by UNSW Brain Sciences, published this month in the Journal of Cerebral Blood Flow and Metabolism, is the first to analyse – in a second-by-second timeframe – what is happening in the brains of sufferers as they sleep. Previous studies have focused on recreating oxygen impairment in awake patients.

“It used to be thought that apneic snoring had absolutely no acute effects on brain function but this is plainly not true,” said lead author of the study, New South Global Professor Caroline Rae.

Sleep apnea affects as many as one in four middle-aged men, with around three percent going on to experience a severe form of the condition characterised by extended pauses in breathing, repetitive asphyxia and sleep fragmentation.

Children with enlarged tonsils and adenoids are also affected, raising concerns of long-term cognitive damage.

Professor Rae and collaborators from Sydney University’s Woolcock Institute used magnetic resonance spectroscopy to study the brains of 13 men with severe, untreated, obstructive sleep apnea. They found that even a moderate degree of oxygen desaturation during the patients’ sleep had significant effects on the brain’s bioenergetic status.

“The findings show that lack of oxygen while asleep may be far more detrimental than when awake, possibly because the normal compensatory mechanisms don't work as well when you are asleep,” Professor Rae, who is based at the Prince of Wales Medical Research Institute, said.

“This is happening in someone with sleep apnea acutely and continually when they are asleep. It’s a completely different biochemical mechanism from anything we’ve seen

before and is similar to what you see in somebody who has had a very severe stroke or is dying.”

The findings suggested societal perceptions of snoring needed to change, Professor Rae said.

“People look at people snoring and think it’s funny. That has to stop.”

Professor Rae said it was still unclear why the body responded to oxygen depletion in this way. It could be a form of ischemic preconditioning at work, much like in heart attack sufferers whose initial attack makes them more protected from subsequent attacks.

“The brain could be basically resetting its bioenergetics to make itself more resistant to lack of oxygen,” Professor Rae said. “It may be a compensatory mechanism to keep you alive, we just don’t know, but even if it is it’s not likely to be doing you much good.”

Sleep apnea has long been known to be associated with obesity. But a new study published in the June issue of Diabetes Care finds that the disorder is widely undiagnosed among obese individuals with type 2 diabetes – nearly 87 percent of participants reported symptoms, but were never diagnosed.

For those with untreated sleep apnea, it doesn't just mean their sleep is disrupted; existing research shows that it can also mean an increased risk of heart disease and stroke.

"The high prevalence of undiagnosed, and therefore, untreated sleep apnea among obese patients with diabetes constitutes a serious public health problem," said Gary Foster, PhD, lead author and director of the Center for Obesity Research and Education at Temple University.

The new study, called Sleep AHEAD, looked at 306 obese patients with type 2 diabetes already enrolled in the Look AHEAD trial, a 16-site study investigating the long-term health impact of an intensive lifestyle intervention in 5, 145 overweight or obese adults with type 2 diabetes.

Each participant had a sleep study (polysomnogram) that measures various breathing and brain activity during sleep. Participants also filled out a series of questions about symptoms related to sleep (snoring, sleepiness during the day), and had their weight, height, waist and neck circumferences measured.

Researchers found that 86.6 percent of participants had sleep apnea, yet reported never being diagnosed. More than 30 percent of these had between 16 and 20 episodes per hour where they would stop breathing, and 22 percent had more than 30 episodes per hour, considered severe sleep apnea. Most of these also had a larger waist circumference, which researchers found, along with higher BMI, to be significantly associated with sleep apnea.

Obesity has long been known to be associated with sleep apnea, but researchers say that these findings are alarming.

"Doctors who have obese patients with type 2 diabetes need to be aware of the possibility of sleep apnea, even if no symptoms are present, especially in cases where the patient has a high BMI or waist circumference," said Foster.

Currently, more than half of obese or overweight individuals have diabetes, the seventh leading cause of death in the United States.

Other authors on the study were Kelley Borradaile, PhD from Temple University; Mark Sanders, MD, Anne Newman, MD, David Kelley, MD, from the University of Pittsburgh; Richard Millman, MD, Rena Wing, PhD from Brown University; Garry Zammit, MD from Clinilabs; Thomas Wadden, PhD, Valerie Darcey, MS, and Samuel Kuna from the University of Pennsylvania; F. Xavier Pi SUnyer from Columbia University; and the Sleep AHEAD Research Group. Funding was provided by grants from the National Institutes of Health: National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive and Kidney Diseases.